Provider Demographics
NPI:1679804116
Name:KENNETH BANKS MD PA
Entity Type:Organization
Organization Name:KENNETH BANKS MD PA
Other - Org Name:KENNETH BANKS MD
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:KENNETH
Authorized Official - Middle Name:
Authorized Official - Last Name:BANKS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:919-269-9144
Mailing Address - Street 1:PO BOX 707
Mailing Address - Street 2:
Mailing Address - City:DURHAM
Mailing Address - State:NC
Mailing Address - Zip Code:27702-0707
Mailing Address - Country:US
Mailing Address - Phone:919-255-1408
Mailing Address - Fax:919-212-9029
Practice Address - Street 1:2949 NEW BERN AVENUE
Practice Address - Street 2:SUITE 112A
Practice Address - City:RALEIGH
Practice Address - State:NC
Practice Address - Zip Code:27610
Practice Address - Country:US
Practice Address - Phone:919-255-1408
Practice Address - Fax:919-212-9029
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-01-22
Last Update Date:2012-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC18602207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC8912978Medicaid
NC8912978Medicaid
NC201687FMedicare PIN
D26813Medicare UPIN
NCD26813Medicare UPIN